The lives of 465 patients were shortened because they were given opioid drugs without medical justification.

A further 200 patients may have had their lives shortened, but their records are missing.

There was “a disregard for human life and a culture of shortening the lives of a large number of patients”.

Dr Jane Barton, the GP who worked as a clinical assistant at the hospital for 12 years, and was responsible for prescribing on the wards, routinely overprescribed drugs for her patients.

Nursing staff raised concerns about prescribing practice as far back as 1988.

In December 1991, a staff meeting was held supposedly for nurses to address the issue but the panel found it “had the effect of silencing the nurses’ concerns”.

Consultants were aware of Barton’s actions but did not intervene.

Nurses did not exercise their responsibility to challenge Barton but continued to administer the drugs.

When relatives complained about the safety of patients and the appropriateness of their care, they were “consistently let down by those in authority”.

Hampshire constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council all failed to act in ways that would have better protected patients and relatives.

The panel did not have the remit to call for prosecutions but directed the health secretary, the attorney general, the chief constable of Hampshire police and the relevant investigatory authorities “to recognise the significance of what is revealed about the circumstances of deaths at the hospital and act accordingly”.